Methods and compositions for preventing type 1 diabetes

ABSTRACT

Provided herein, in one aspect, is a method of preventing or delaying the onset of clinical type 1 diabetes (T1D), comprising: providing a non-diabetic subject who is at risk for T1D; determining that the non-diabetic subject (1) is substantially free of antibodies against zinc transporter 8 (ZnT8), (2) is HLA-DR4+, and/or (3) is not HLA-DR3+; and administering a prophylactically effective amount of an anti-CD3 antibody to the non-diabetic subject.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims priority to and the benefit of U.S. Provisional Application No. 62/847,466 filed May 14, 2019, the entire disclosure of which is incorporated herein by reference.

GOVERNMENT SUPPORT

This invention was made with United States Government support under grant numbers 5U01DK061041, 5U01DK061037, 5U01DK085499, 2U01DK106993, U01DK085466, R01 DK057846 awarded by National Institutes of Health, and grant numbers HHSN267200800019C, 1UC4DK097835, 1UC4DK117009 awarded by National Institute of Diabetes and Digestive and Kidney Diseases. The United States Government has certain rights in the invention.

SEQUENCE LISTING

The ASCII text file submitted on May 14, 2020 via EFS-Web, entitled “010701seq.txt” created on May 14, 2020, having a size of 6,083 bytes, is incorporated herein by reference in its entirety.

FIELD

The present disclosure relates in general to compositions and methods of preventing or delaying the onset of clinical type 1 diabetes (T1D) in subjects at risk, and more particularly the use of anti-CD3 antibodies.

BACKGROUND

Type 1 diabetes (T1D) is caused by the autoimmune destruction of insulin producing beta cells in the islets of Langerhans leading to dependence on exogeneous insulin injections for survival. Approximately 1.6 million Americans have Type 1 diabetes, and after asthma, it remains one of the most common diseases of childhood¹. Despite improvements in care most affected individuals with T1D are not able to consistently achieve desired glycemic targets². For individuals with type 1 diabetes, there are persisting concerns for increased risk of both morbidity and mortality. Two recent studies noted loss of 17.7 life-years for children diagnosed before age 10, and 11 and 13 life-years lost for adult-diagnosed Scottish men and women respectively^(3,4).

In genetically susceptible individuals, T1D progresses through asymptomatic stages prior to overt hyperglycemia, characterized first by the appearance of autoantibodies (Stage 1) and then dysglycemia (Stage 2). In Stage 2, metabolic responses to a glucose load are impaired but other metabolic indices, for example glycosylated hemoglobin, are normal and insulin treatment is not needed⁵. These immunologic and metabolic features identify individuals who are at high-risk for development of clinical disease with overt hyperglycemia and requirement for insulin treatment (Stage 3). Several immune interventions have been shown to delay decline in beta cell function when studied in recent-onset clinical T1D⁶. One promising therapy is the FcR non-binding anti-CD3 monoclonal antibody teplizumab, as several studies have shown that short-term treatment reduces loss of β cell function durably, with an observable effect seen as long as 7 years after diagnosis and treatment⁷⁻¹¹. The drug modifies the function of CD8+T lymphocytes, which are thought to be important effector cells that cause beta cell killing^(12,13).

To date, no intervention initiated before the clinical diagnosis (i.e., at Stage 1 or 2) has altered progression to clinical, Stage 3 T1D. Thus, a need exists for a treatment that would prevent or delay the onset of clinical T1D in high-risk individuals.

SUMMARY

In one aspect, a method of preventing or delaying the onset of clinical type 1 diabetes (T1D) is provided, comprising:

-   -   providing a non-diabetic subject who is at risk for T1D;     -   determining that the non-diabetic subject (1) is substantially         free of antibodies against zinc transporter 8 (ZnT8), (2) is         HLA-DR4+, and/or (3) is not HLA-DR3+; and     -   administering a prophylactically effective amount of an anti-CD3         antibody to the non-diabetic subject.

In some embodiments, the non-diabetic subject is a relative of a patient with T1D. In certain embodiments, the non-diabetic subject has 2 or more diabetes-related autoantibodies selected from islet cell antibodies (ICA), insulin autoantibodies (IAA), and antibodies to glutamic acid decarboxylase (GAD), tyrosine phosphatase (IA-2/ICA512) or ZnT8.

In some embodiments, the detection of T1D-associated autoantibodies is done by point-of-care (POC) screening methods in the general population, or relatives of patients with T1D. Those POC methods can be qualitative rapid lateral flow tests.

In some embodiments, the non-diabetic subject has an infection by coxsackie B virus (CVB) and/or other beta-cell tropic virus(es). In some embodiments, this subject infected with a beta cell-tropic virus has HLA-DR4 and is more responsive to teplizumab.

In various embodiments, the non-diabetic subject has abnormal glucose tolerance on oral glucose tolerance test (OGTT). Abnormal glucose tolerance on OGTT is defined as a fasting glucose level of 110-125 mg/dL, or 2 hour plasma of ≥140 and <200 mg/dL, or an intervening glucose value at 30, 60, or 90 minutes on OGTT >200 mg/dL.

In some embodiments, the non-diabetic subject does not have antibodies against ZnT8. In certain embodiments, the non-diabetic subject is HLA-DR4+ and is not HLA-DR3+.

In one embodiment, the anti-CD3 antibody is teplizumab.

In various embodiments, the prophylactically effective amount comprises a 10 to 14 day daily course of subcutaneous (SC) injection or intravenous (IV) infusion of the anti-CD3 antibody, e.g., teplizumab, at 10-1000 micrograms/meter squared (μg/m²), for a total dose of 6-15 milligrams of anti-CD3/teplizumab, preferably a 14-day course IV infusion of teplizumab at 51 μg/m², 103 μg/m², 207 μg/m², and 413 μg/m², on days 0-3, respectively, and one dose of 826 μg/m² on each of days 4-13. In certain embodiments, the prophylactically effective amount of the anti-CD3 antibody, e.g., teplizumab, delays median time to clinical diagnosis of T1D by at least 50%, at least 80%, or at least 90%, or at least 12 months, at least 18 months, at least 24 months, at least 36 months, at least 48 months, or at least 60 months, or longer.

In some embodiments, the anti-CD3 antibody, e.g., teplizumab, otelixizumab or foralumab, is administered in a SC pump or embedded in a slow-release biomaterial or administered orally. In other embodiments, the anti-CD3 antibody, e.g., teplizumab, otelixizumab or foralumab, is embedded in a biomaterial encapsulating beta cell precursors or beta cells or provided parenterally in conjunction with beta cell precursors or beta cells.

In some embodiments, the anti-CD3 antibody, e.g., teplizumab, otelixizumab or foralumab, is administered in combination with other pharmacological agents, such as metabolic agents, B cell inhibitors or other immune modulating agents.

In some embodiments, the anti-CD3 antibody, e.g., teplizumab, otelixizumab or foralumab, is administered with antigen-specific immune therapies and/or vaccines.

In some embodiments, the method further comprises determining, by flow cytometry, a frequency of TIGIT+KLRG1+CD8+ T-cells in peripheral blood mononuclear cells of the non-diabetic subject, wherein an increase in the frequency after administrating the anti-CD3 antibody, e.g., teplizumab, otelixizumab or foralumab, indicates responsiveness to the anti-CD3 antibody, e.g., teplizumab.

Another aspect relates to a method of prognosing responsiveness of an anti-CD3 antibody, e.g., teplizumab, otelixizumab or foralumab, in preventing or delaying the onset of type 1 diabetes (T1D), comprising:

-   -   providing a non-diabetic subject who is at risk for T1D;     -   administering a prophylactically effective amount of teplizumab,         otelixizumab or foralumab to the non-diabetic subject; and     -   determining, by flow cytometry, a frequency of TIGIT+KLRG1+CD8+         T-cells in peripheral blood mononuclear cells of the         non-diabetic subject, wherein an increase in the frequency         indicates responsiveness to the anti-CD3 antibody, e.g.,         teplizumab, otelixizumab or foralumab.

In some embodiments, the method can further include determining that the non-diabetic subject (1) is substantially free of antibodies against zinc transporter 8 (ZnT8), (2) is HLA-DR4+, and/or (3) is not HLA-DR3+.

It will be clear for the person skilled in the art that aspects and/or embodiments as described herein may be combined.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1: Screening, enrollment and follow-up of the participants. A total of 112 subjects were screened for eligibility at TrialNet sites (see Appendix for a listing of study sites). Seventy-six of the subjects were randomized to the drug or placebo arms. They were infused with study drug at one of 14 TrialNet sites and followed, as per study protocol at one of 33 sites. All randomized subjects are included in the analysis.

FIGS. 2A-2C: Effects of teplizumab treatment on development of T1D. FIG. 2A. Kaplan-Meier estimates of the proportion of participants who were diabetes free. The overall hazard ratio was 0.437 (95% CI:0.229, 0.832) (p=0.006, one sided, Cox model). The median time to T1D was 48.4 mos for teplizumab group and 24.4 mos for the placebo group. The insert shows the total number of subjects with T1D and diabetes free at the conclusion of the study. FIG. 2B. Frequency of type I diabetes by treatment group and cumulative and interval hazard ratios (95% confidence Intervals) by year on-study. (* The number of participants developing T1D in each treatment arm during the year interval are shown. In addition, the cumulative HRs and the HR for each year interval were calculated. † Mantel-Haenszel method applied to time-to-event data, both chi-square test and hazard ratio estimate³⁴. € Likelihood ratio test and hazard ratio estimate and 95% CI from the Cox model). FIG. 2C. Absolute lymphocyte counts (ALC) in the study groups.

FIGS. 3A-3E: Immunologic effects and subgroup analysis of responses to teplizumab. FIG. 3A. Frequency of CD8+KLRG1+TIGIT+CD57− T-cells in the teplizumab and placebo treated subjects. (* p<0.05 in teplizumab- vs placebo-treated participants). The mean±95% CI are shown. The comparisons were made with an ANCOVA for each time point and corrected for the baseline values. In addition, there was a significant increase in the frequency of these cells in the teplizumab treated participants at 3 mos (p=0.009) and 6 mos (p=0.007) but not in the placebo treated participants (paired t-test). FIG. 3B. The ladder plot shows the hazard rate for each of the indicated features of the participants at baseline. The absence of anti-ZnT8 antibody (p=0.004, HR: 0.031 for negative, 0.657 for positive), presence of HLA-DR4 (p=0.004, HR: 1.47 for negative, 0.201 for positive), and absence of HLA-DR3 (p=0.01, HR:0.181 for negative, 0.907 for positive) had significant effects on the hazard ratio. The development of diabetes in patients with or without anti-ZnT8 antibodies at baseline (FIG. 3C), or positive or negative for HLA-DR3 (FIG. 3D) or HLA-DR4 (FIG. 3E) are shown.

FIG. 4: Monoclonal antibodies used in flow cytometry.

FIG. 5: Enrollment in trial.

FIG. 6: FACS contour plots showing staining of TIGIT (Y axis) vs KLRG1 (X axis). Electronic gates were placed on live CD8+CD57− T cells and the expression of KLRG1 and TIGIT are shown in peripheral blood cells from 3 subjects treated with teplizumab (top row) and 3 subjects treated with placebo. The numbers refer to the proportion of the total gated cells in each quadrant. The quadrants were placed based on staining controls.

FIGS. 7A-7B: Frequency of T cell subsets in the treatment groups. The frequency of CD4+ Tregs (FIG. 7A) CD4+CD127_(lo)Foxp3+ and (FIG. 7B) CD8+TIGIT-KLRG1-CD57− T cells at the study visits is shown. The differences in both cell subsets between teplizumab and placebo and from baseline to after treatment for each treatment arm were not statistically significant when compared by ANCOVA for each time point and corrected for the baseline values.

DETAILED DESCRIPTION

The present disclosure provides, in some embodiments, the surprising discoveries that non-diabetic subjects who will respond to anti-CD3 antibody, e.g., teplizumab, treatment does not have antibodies against ZnT8. In certain embodiments, such non-diabetic subjects are HLA-DR4+ and are not HLA-DR3+. Unexpectedly, such non-diabetic subjects who will respond to the anti-CD3 antibody treatment demonstrate an increase, following teplizumab administration (e.g., after 1 month, after 2 months, after 3 months, or longer or shorter), in the frequency (or relative amount) of TIGIT+KLRG1+CD8+ T-cells (e.g., by flow cytometry) in peripheral blood mononuclear cells.

Provided herein, in some embodiments, is a method of preventing or delaying the onset of clinical type 1 diabetes (T1D), comprising: providing a non-diabetic subject who is at risk for T1D; determining that the non-diabetic subject (1) is substantially free of antibodies against zinc transporter 8 (ZnT8), (2) is HLA-DR4+, and/or (3) is not HLA-DR3+; and administering a prophylactically effective amount of an anti-CD3 antibody, e.g., teplizumab, to the non-diabetic subject.

In certain embodiments, a method of prognosing responsiveness of an anti-CD3 antibody, e.g., teplizumab, in preventing or delaying the onset of T1D is provided. The method can include: providing a non-diabetic subject who is at risk for T1D; administering a prophylactically effective amount of the anti-CD3 antibody, e.g., teplizumab, to the non-diabetic subject; and determining, by flow cytometry, a frequency of TIGIT+KLRG1+CD8+ T-cells in peripheral blood mononuclear cells of the non-diabetic subject, wherein an increase in the frequency indicates responsiveness to the anti-CD3 antibody, e.g., teplizumab.

Definitions

Certain terms are defined herein below. Additional definitions are provided throughout the application.

As used herein, the articles “a” and “an” refer to one or more than one, e.g., to at least one, of the grammatical object of the article. The use of the words “a” or “an” when used in conjunction with the term “comprising” herein may mean “one,” but it is also consistent with the meaning of “one or more,” “at least one,” and “one or more than one.”

As used herein, “about” and “approximately” generally mean an acceptable degree of error for the quantity measured given the nature or precision of the measurements. Exemplary degrees of error are within 20 percent (%), typically, within 10%, and more typically, within 5% of a given range of values. The term “substantially” means more than 50%, preferably more than 80%, and most preferably more than 90% or 95%.

As used herein the term “comprising” or “comprises” is used in reference to compositions, methods, and respective component(s) thereof, that are present in a given embodiment, yet open to the inclusion of unspecified elements.

As used herein the term “consisting essentially of” refers to those elements required for a given embodiment. The term permits the presence of additional elements that do not materially affect the basic and novel or functional characteristic(s) of that embodiment of the disclosure.

The term “consisting of” refers to compositions, methods, and respective components thereof as described herein, which are exclusive of any element not recited in that description of the embodiment.

The term “antibody” herein is used in the broadest sense and encompasses various antibody structures, including but not limited to monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g., bispecific antibodies), and antibody fragments so long as they exhibit the desired antigen-binding activity.

An “antibody fragment” refers to a molecule other than an intact antibody that comprises a portion of an intact antibody that binds the antigen to which the intact antibody binds. Examples of antibody fragments include but are not limited to Fv, Fab, Fab′, Fab′-SH, F(ab′)₂; diabodies; linear antibodies; single-chain antibody molecules (e.g. scFv); and multispecific antibodies formed from antibody fragments.

As used herein, the term “prophylactic agent” refer to CD3 binding molecules such as teplizumab which can be used in the prevention, treatment, management or amelioration of one or more symptoms of T1D.

As used herein, the term “onset” of disease with reference to Type-1 diabetes refers to a patient meeting the criteria established for diagnosis of Type-1 diabetes by the American Diabetes Association (see, Mayfield et al., 2006, Am. Fam. Physician 58:1355-1362).

As used herein, the terms “prevent”, “preventing” and “prevention” refer to the prevention of the onset of one or more symptoms of T1D in a subject resulting from the administration of a prophylactic or therapeutic agent.

As used herein, a “protocol” includes dosing schedules and dosing regimens. The protocols herein are methods of use and include prophylactic and therapeutic protocols. A “dosing regimen” or “course of treatment” may include administration of several doses of a therapeutic or prophylactic agent over 1 to 20 days.

As used herein, the terms “subject” and “patient” are used interchangeably. As used herein, the terms “subject” and “subjects” refer to an animal, preferably a mammal including a non-primate (e.g., a cow, pig, horse, cat, dog, rat, and mouse) and a primate (e.g., a monkey or a human), and more preferably a human.

As used herein, the term “prophylactically effective amount” refers to that amount of teplizumab sufficient to result in the delay or prevention of the development, recurrence or onset of one or more symptoms of T1D. In some embodiments, a prophylactically effective amount preferably refers to the amount of teplizumab that delays a subject's onset of T1D by at least 20%, by at least 25%, by at least 30%, by at least 35%, by at least 40%, by at least 45%, by at least 50%, by at least 55%, by at least 60%, by at least 65%, by at least 70%, by at least 75%, by at least 80%, by at least 85%, by at least 90%, by at least 95%.

Various aspects of the disclosure are described in further detail below. Additional definitions are set out throughout the specification.

Anti-CD3 Antibodies and Pharmaceutical Compositions

The terms “anti-CD3 antibody” and “an antibody that binds to CD3” refer to an antibody or antibody fragment that is capable of binding cluster of differentiation 3 (CD3) with sufficient affinity such that the antibody is useful as a prophylactic, diagnostic and/or therapeutic agent in targeting CD3. In one embodiment, the extent of binding of an anti-CD3 antibody to an unrelated, non-CD3 protein is less than about 10% of the binding of the antibody to CD3 as measured, e.g., by a radioimmunoassay (MA). In certain embodiments, an antibody that binds to CD3 has a dissociation constant (Kd) of <1 μM, <100 nM, <10 nM, <1 nM, <0.1 nM, <0.01 nM, or <0.001 nM (e.g. 10⁻⁸M or less, e.g. from 10⁻⁸M to 10⁻¹³M, e.g., from 10⁻⁹ M to 10⁻¹³M). In certain embodiments, an anti-CD3 antibody binds to an epitope of CD3 that is conserved among CD3 from different species.

In one embodiment, the anti-CD3 antibody can be ChAglyCD3 (otelixizumab). Otelixizumab is a humanized Fc nonbinding anti-CD3, which was evaluated initially in phase 2 studies by the Belgian Diabetes Registry (BDR) and then developed by Tolerx, which then partnered with GSK to conduct the phase 3 DEFEND new onset T1D trials (NCT00678886, NCT01123083, NCT00763451). Otelixizumab is administered IV with infusions over 8 days. See, e.g., Wiczling et al., J. Clin. Pharmacol. 50 (5) (May 2010) 494-506; Keymeulen et al., N Engl J Med. 2005; 352:2598-608; Keymeulen et al., Diabetologia. 2010; 53:614-23; Hagopian et al., Diabetes. 2013; 62:3901-8; Aronson et al., Diabetes Care. 2014; 37:2746-54; Ambery et al., Diabet Med. 2014; 31:399-402; Bolt et al., Eur. J. Immunol. lYY3. 23: 403-411; Vlasakakis et al., Br J Clin Pharmacol (2019) 85 704-714; Guglielmi et al, Expert Opinion on Biological Therapy, 16:6, 841-846; Keymeulen et al., N Engl J Med 2005; 352:2598-608; Keymeulen et al., BLOOD 2010, VOL 115, No. 6; Sprangers et al., Immunotherapy (2011) 3(11), 1303-1316; Daifotis et al., Clinical Immunology (2013) 149, 268-278; all incorporated herein by reference.

In another embodiment, the anti-CD3 antibody can be visilizumab (also called HuM291; Nuvion). Visilizumab is a humanized anti-CD3 monoclonal antibody characterized by a mutated IgG2 isotype, lack of binding to Fcγ receptors, and the ability to induce apoptosis selectively in activated T cells. It has evaluated in patients in graft-versus-host disease (NCT00720629; NCT00032279) and in ulcerative colitis (NCT00267306) and Crohn's Disease (NCT00267709). See, e.g., Sandborn et al., Gut 59 (11) (November 2010) 1485-1492, incorporated herein by reference.

In another embodiment, the anti-CD3 antibody can be foralumab, a fully human anti-CD3 monoclonal antibody being developed by Tiziana Life Sciences, PLC in NASH and T2D (NCT03291249). See, e.g., Ogura et al., Clin Immunol. 2017; 183:240-246; Ishikawa et al., Diabetes. 2007; 56(8):2103-9; Wu et al., J Immunol. 2010; 185(6):3401-7; all incorporated herein by reference.

In another embodiment, the anti-CD3 antibody can be teplizumab. Teplizumab, also known as hOKT3yl (Ala-Ala) (containing an alanine at positions 234 and 235) is an anti-CD3 antibody that had been engineered to alter the function of the T lymphocytes that mediate the destruction of the insulin-producing beta cells of the islets of the pancreas. Teplizumab binds to an epitope of the CD3s chain expressed on mature T cells and by doing so changes their function. Sequences and compositions of teplizumab are disclosed in U.S. Pat. Nos. 6,491,916; 8,663,634; and 9,056,906, each incorporated herein by reference in its entirety. The full sequences of light and heavy chains are set forth below. Bolded portions are the complementarity determining regions.

Teplizumab Light Chain (SEQ ID NO: 1): DIQMTQSPSSLSASVGDRVTITCSASSSVSYMNWYQQTPGKAPKRWIYDT SKLASGVPSRFSGSGSGTDYTFTISSLQPEDIATYYCQQWSSNPFTFGQG TKLQITRTVAAPSVFIFPPSDEQLKSGTASVVCLLNNFYPREAKVQWKVD NALQSGNSQESVTEQDSKDSTYSLSSTLTLSKADYEKHKVYACEVTHQGL SSPVTKSFNRGEC Teplizumab Heavy Chain (SEQ ID NO: 2): QVQLVQSGGGVVQPGRSLRLSCKASGYTFTRYTMHWVRQAPGKGLEWIGY INPSRGYTNYNQKVKDRFTISRDNSKNTAFLQMDSLRPEDTGVYFCARYY DDHYCLDYWGQGTPVTVSSASTKGPSVFPLAPSSKSTSGGTAALGCLVKD YFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQTY ICNVNHKPSNTKVDKKVEPKSCDKTHTCPPCPAPEAAGGPSVFLEPPKPK DTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNS TYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQV YTLPPSRDELTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVL DSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

In some embodiments, provided herein is a pharmaceutical composition. Such compositions comprise a prophylactically effective amount of an anti-CD3 antibody, and a pharmaceutically acceptable carrier. In a specific embodiment, the term “pharmaceutically acceptable” means approved by a regulatory agency of the Federal or a state government or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in animals, and more particularly in humans. The term “carrier” refers to a diluent, adjuvant (e.g., Freund's adjuvant (complete and incomplete)), excipient, or vehicle with which the therapeutic is administered. Such pharmaceutical carriers can be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable or synthetic origin, such as peanut oil, soybean oil, mineral oil, sesame oil and the like. Water is a preferred carrier when the pharmaceutical composition is administered intravenously. Saline solutions and aqueous dextrose and glycerol solutions can also be employed as liquid carriers, particularly for injectable solutions. Suitable pharmaceutical excipients include starch, glucose, lactose, sucrose, gelatin, malt, rice, flour, chalk, silica gel, sodium stearate, glycerol monostearate, talc, sodium chloride, dried skim milk, glycerol, propylene, glycol, water, ethanol and the like (See, for example, Handbook of Pharmaceutical Excipients, Arthur H. Kibbe (ed., 2000, which is incorporated by reference herein in its entirety), Am. Pharmaceutical Association, Washington, D.C.

The composition, if desired, can also contain minor amounts of wetting or emulsifying agents, or pH buffering agents. These compositions can take the form of solutions, suspensions, emulsion, tablets, pills, capsules, powders, sustained release formulations and the like. Oral formulation can include standard carriers such as pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharine, cellulose, magnesium carbonate, etc. Examples of suitable pharmaceutical carriers are described in “Remington's Pharmaceutical Sciences” by E. W. Martin. Such compositions will contain a prophylactically or therapeutically effective amount of a prophylactic or therapeutic agent preferably in purified form, together with a suitable amount of carrier so as to provide the form for proper administration to the patient. The formulation should suit the mode of administration. In a preferred embodiment, the pharmaceutical compositions are sterile and in suitable form for administration to a subject, preferably an animal subject, more preferably a mammalian subject, and most preferably a human subject.

In a specific embodiment, it may be desirable to administer the pharmaceutical compositions locally to the area in need of treatment; this may be achieved by, for example, and not by way of limitation, local infusion, by injection, or by means of an implant, said implant being of a porous, non-porous, or gelatinous material, including membranes, such as sialastic membranes, or fibers. Preferably, when administering the anti-CD3 antibody, care must be taken to use materials to which the anti-CD3 antibody does not absorb.

In another embodiment, the composition can be delivered in a vesicle, in particular a liposome (see Langer, Science 249:1527-1533 (1990); Treat et al., in Liposomes in the Therapy of Infectious Disease and Cancer, Lopez-Berestein and Fidler (eds.), Liss, New York, pp. 353-365 (1989); Lopez-Berestein, ibid., pp. 317-327; see generally ibid.).

In yet another embodiment, the composition can be delivered in a controlled release or sustained release system. In one embodiment, a pump may be used to achieve controlled or sustained release (see Langer, supra; Sefton, 1987, CRC Crit. Ref. Biomed. Eng. 14:20; Buchwald et al., 1980, Surgery 88:507; Saudek et al., 1989, N. Engl. J. Med. 321:574). In another embodiment, polymeric materials can be used to achieve controlled or sustained release of the antibodies of the invention or fragments thereof (see e.g., Medical Applications of Controlled Release, Langer and Wise (eds.), CRC Pres., Boca Raton, Fla. (1974); Controlled Drug Bioavailability, Drug Product Design and Performance, Smolen and Ball (eds.), Wiley, New York (1984); Ranger and Peppas, 1983, J., Macromol. Sci. Rev. Macromol. Chem. 23:61; see also Levy et al., 1985, Science 228:190; During et al., 1989, Ann. Neurol. 25:351; Howard et al., 1989, J. Neurosurg. 71:105); U.S. Pat. Nos. 5,679,377; 5,916,597; 5,912,015; 5,989,463; 5,128,326; PCT Publication No. WO 99/15154; and PCT Publication No. WO 99/20253. Examples of polymers used in sustained release formulations include, but are not limited to, poly(2-hydroxy ethyl methacrylate), poly(methyl methacrylate), poly(acrylic acid), poly(ethylene-co-vinyl acetate), poly(methacrylic acid), polyglycolides (PLG), polyanhydrides, poly(N-vinyl pyrrolidone), poly(vinyl alcohol), polyacrylamide, poly(ethylene glycol), polylactides (PLA), poly(lactide-co-glycolides) (PLGA), and polyorthoesters. In a preferred embodiment, the polymer used in a sustained release formulation is inert, free of leachable impurities, stable on storage, sterile, and biodegradable. In yet another embodiment, a controlled or sustained release system can be placed in proximity of the therapeutic target, i.e., the lungs, thus requiring only a fraction of the systemic dose (see, e.g., Goodson, in Medical Applications of Controlled Release, supra, vol. 2, pp. 115-138 (1984)).

Controlled release systems are discussed in the review by Langer (1990, Science 249:1527-1533). Any technique known to one of skill in the art can be used to produce sustained release formulations comprising one or more antibodies of the invention or fragments thereof. See, e.g., U.S. Pat. No. 4,526,938; PCT publication WO 91/05548; PCT publication WO 96/20698; Ning et al., 1996, Radiotherapy & Oncology 39:179-189; Song et al., 1995, PDA Journal of Pharmaceutical Science & Technology 50:372-397; Cleek et al., 1997, Pro. Int'l. Symp. Control. Rel. Bioact. Mater. 24:853-854; and Lam et al., 1997, Proc. Int'l. Symp. Control Rel. Bioact. Mater. 24:759-760, each of which is incorporated herein by reference in its entirety.

A pharmaceutical composition can be formulated to be compatible with its intended route of administration. Examples of routes of administration include, but are not limited to, parenteral, e.g., intravenous, intradermal, subcutaneous, oral, intranasal (e.g., inhalation), transdermal (topical), transmucosal, and rectal administration. In a specific embodiment, the composition is formulated in accordance with routine procedures as a pharmaceutical composition adapted for intravenous, subcutaneous, intramuscular, oral, intranasal or topical administration to human beings. In a preferred embodiment, a pharmaceutical composition is formulated in accordance with routine procedures for subcutaneous administration to human beings. Typically, compositions for intravenous administration are solutions in sterile isotonic aqueous buffer. Where necessary, the composition may also include a solubilizing agent and a local anesthetic such as lignocamne to ease pain at the site of the injection.

The compositions may be formulated for parenteral administration by injection, e.g., by bolus injection or continuous infusion. Formulations for injection may be presented in unit dosage form, e.g., in ampoules or in multi-dose containers, with an added preservative. The compositions may take such forms as suspensions, solutions or emulsions in oily or aqueous vehicles, and may contain formulatory agents such as suspending, stabilizing and/or dispersing agents. Alternatively, the active ingredient may be in powder form for constitution with a suitable vehicle, e.g., sterile pyrogen-free water, before use.

In specific embodiments, the disclosure provides dosage forms that permit administration of the anti-CD3 antibody continuously over a period of hours or days (e.g., associated with a pump or other device for such delivery), for example, over a period of 1 hour, 2 hours, 3 hours, 4 hours, 6 hours, 8 hours, 10 hours, 12 hours. 16 hours, 20 hours, 24 hours, 30 hours, 36 hours, 4 days, 5 days, 7 days, 10 days or 14 days. In other specific embodiments, the invention provides dosage forms that permit administration of a continuously increasing dose, for example, increasing from 51 ug/m²/day to 826 ug/m²/day over a period of 24 hours, 30 hours, 36 hours, 4 days, 5 days, 7 days, 10 days or 14 days.

The compositions can be formulated as neutral or salt forms. Pharmaceutically acceptable salts include those formed with anions such as those derived from hydrochloric, phosphoric, acetic, oxalic, tartaric acids, etc., and those formed with cations such as those derived from sodium, potassium, ammonium, calcium, ferric hydroxides, isopropylamine, triethylamine, 2-ethylamino ethanol, histidine, procaine, etc.

Generally, the ingredients of the compositions disclosed herein are supplied either separately or mixed together in unit dosage form, for example, as a dry lyophilized powder or water free concentrate in a hermetically sealed container such as an ampoule or sachette indicating the quantity of active agent. Where the composition is to be administered by infusion, it can be dispensed with an infusion bottle containing sterile pharmaceutical grade water or saline. Where the composition is administered by injection, an ampoule of sterile water for injection or saline can be provided so that the ingredients may be mixed prior to administration.

In particular, the disclosure provides that the anti-CD3 antibodies, or pharmaceutical compositions thereof, can be packaged in a hermetically sealed container such as an ampoule or sachette indicating the quantity of the agent. In one embodiment, the anti-CD3 antibody, or pharmaceutical compositions thereof is supplied as a dry sterilized lyophilized powder or water free concentrate in a hermetically sealed container and can be reconstituted, e.g., with water or saline to the appropriate concentration for administration to a subject. Preferably, the anti-CD3 antibody, or pharmaceutical compositions thereof is supplied as a dry sterile lyophilized powder in a hermetically sealed container at a unit dosage of at least 5 mg, more preferably at least 10 mg, at least 15 mg, at least 25 mg, at least 35 mg, at least 45 mg, at least 50 mg, at least 75 mg, or at least 100 mg. The lyophilized prophylactic agents, or pharmaceutical compositions herein should be stored at between 2 and 8° C. in its original container and the prophylactic or therapeutic agents, or pharmaceutical compositions of the invention should be administered within 1 week, preferably within 5 days, within 72 hours, within 48 hours, within 24 hours, within 12 hours, within 6 hours, within 5 hours, within 3 hours, or within 1 hour after being reconstituted. In an alternative embodiment, the pharmaceutical composition is supplied in liquid form in a hermetically sealed container indicating the quantity and concentration of the agent. Preferably, the liquid form of the administered composition is supplied in a hermetically sealed container at least 0.25 mg/ml, more preferably at least 0.5 mg/ml, at least 1 mg/ml, at least 2.5 mg/ml, at least 5 mg/ml, at least 8 mg/ml, at least 10 mg/ml, at least 15 mg/kg, at least 25 mg/ml, at least 50 mg/ml, at least 75 mg/ml or at least 100 mg/ml. The liquid form should be stored at between 2° C. and 8° C. in its original container.

In a particular embodiment, the disclosure provides that the composition of the invention is packaged in a hermetically sealed container such as an ampoule or sachette indicating the quantity of the anti-CD3 antibody.

The compositions may, if desired, be presented in a pack or dispenser device that may contain one or more unit dosage forms containing the active ingredient. The pack may for example comprise metal or plastic foil, such as a blister pack.

The amount of the composition of the invention which will be effective in the prevention or amelioration of one or more symptoms associated with T1D can be determined by standard clinical techniques. The precise dose to be employed in the formulation will also depend on the route of administration, and the seriousness of the condition, and should be decided according to the judgment of the practitioner and each patient's circumstances. Effective doses may be extrapolated from dose-response curves derived from in vitro or animal model test systems.

Methods and Use

In certain embodiments, the present disclosure encompasses administration of anti-human CD3 antibodies such teplizumab to individuals predisposed to develop type 1 diabetes or with pre-clinical stages of type 1 diabetes, but who do not meet the diagnosis criteria as established by the American Diabetes Association or the Immunology of Diabetes Society to prevent or delay the onset of type 1 diabetes and/or to prevent or delay the need for administration of insulin to such patients. In certain embodiments, high-risk factors for identification of predisposed subjects include having first or second degree relatives with diagnosed type-1 diabetes, an impaired fasting glucose level (e.g., at least one determination of a glucose level of 100-125 mg/dl after fasting (8 hour with no food)), an impaired glucose tolerance in response to a 75 g OGTT (e.g., at least one determination of a 2-hr glucose level of 140-199 mg/dl in response to a 75 g OGTT), an HLA type of DR3, DR4 or DR7 in a Caucasian, an HLA type of DR3 or DR4 in a person of African descent, an HLA type of DR3, DR4 or DR9 in a person of Japanese descent, exposure to viruses (e.g., coxsackie B virus, enteroviruses, adenoviruses, rubella, cytomegalovirus, Epstein-Barr virus), a positive diagnosis according to art accepted criteria of at least one other autoimmune disorder (e.g., thyroid disease, celiac disease), and/or the detection of autoantibodies, particularly ICAs and type 1 diabetes-associated autoantibodies, in the serum or other tissues. In certain embodiments, the subject identified as predisposed to developing type 1 diabetes has at least one of the risk factors described herein and/or as known in the art. The present disclosure also encompasses identification of subjects predisposed to development of type 1 diabetes, wherein said subject presents a combination of two or more, three or more, four or more, or more than five of the risk factors disclosed herein or known in the art.

Serum autoantibodies associated with type 1 diabetes or with a predisposition for the development of type 1 diabetes are islet-cell autoantibodies (e.g., anti-ICA512 autoantibodies), glutamic acid decarbamylase autoantibodies (e.g., anti-GAD65 autoantibodies), IA2 antibodies, ZnT8 antibodies and/or anti-insulin autoantibodies. Accordingly, in a specific example in accordance with this embodiment, the invention encompasses the treatment of an individual with detectable autoantibodies associated with a predisposition to the development of type 1 diabetes or associated with early stage type 1 diabetes (e.g., anti-IA2, anti-ICA512, anti-GAD or anti-insulin autoantibodies), wherein said individual has not been diagnosed with type 1 diabetes and/or is a first or second degree relative of a type-1 diabetic. In certain embodiments, the presence of the autoantibodies is detected by ELISA, electrochemoluminescence (ECL), radioassay (see, e.g., Yu et al., 1996, J. Clin. Endocrinol. Metab. 81:4264-4267), agglutination PCR (Tsai et al, ACS Central Science 2016 2 (3), 139-147) or by any other method for immunospecific detection of antibodies described herein or as known to one of ordinary skill in the art.

β-cell function prior to, during, and after therapy may be assessed by methods described herein or by any method known to one of ordinary skill in the art. For example, the Diabetes Control and Complications Trial (DCCT) research group has established the monitoring of percentage glycosylated hemoglobin (HA1 and HA1c) as the standard for evaluation of blood glucose control (DCCT, 1993, N. Engl. J. Med. 329:977-986). Alternatively, characterization of daily insulin needs, C-peptide levels/response, hypoglycemic episodes, and/or FPIR may be used as markers of β-cell function or to establish a therapeutic index (See Keymeulen et al., 2005, N. Engl. J. Med. 352:2598-2608; Herold et al., 2005, Diabetes 54:1763-1769; U.S. Pat. Appl. Pub. No. 2004/0038867 A1; and Greenbaum et al., 2001, Diabetes 50:470-476, respectively). For example, FPIR is calculated as the sum of insulin values at 1 and 3 minutes post IGTT, which are performed according to Islet Cell Antibody Register User's Study protocols (see, e.g., Bingley et al., 1996, Diabetes 45:1720-1728 and McCulloch et al., 1993, Diabetes Care 16:911-915).

In some embodiments, the individuals predisposed to develop T1D can be a non-diabetic subject who is a relative of a patient with T1D. In certain embodiments, the non-diabetic subject has 2 or more diabetes-related autoantibodies selected from islet cell antibodies (ICA), insulin autoantibodies (IAA), and antibodies to glutamic acid decarboxylase (GAD), tyrosine phosphatase (IA-2/ICA512) or ZnT8.

In various embodiments, the non-diabetic subject has abnormal glucose tolerance on oral glucose tolerance test (OGTT). Aabnormal glucose tolerance on OGTT is defined as a fasting glucose level of 110-125 mg/dL, or 2 hour plasma of ≥140 and <200 mg/dL, or an intervening glucose value at 30, 60, or 90 minutes on OGTT >200 mg/dL.

In some embodiments, the non-diabetic subject who will respond to the anti-CD3 antibody such as teplizumab does not have antibodies against ZnT8. In certain embodiments, such non-diabetic subject is HLA-DR4+ and is not HLA-DR3+. In some embodiments, such non-diabetic subject who will respond to the anti-CD3 antibody such as teplizumab demonstrates an increase, following administration (e.g., after 1 month, after 2 months, after 3 months, or longer or shorter), in the frequency (or relative amount) of TIGIT+KLRG1+CD8+ T-cells (e.g., by flow cytometry) in peripheral blood mononuclear cells.

In various embodiments, the prophylactically effective amount comprises a 10 to 14 day course of subcutaneous (SC) injection or intravenous (IV) infusion of the anti-CD3 antibody such as teplizumab at 10-1000 micrograms/meter squared (μg/m²). In one example, the prophylactically effective amount comprises a 14-day course IV infusion of the anti-CD3 antibody such as teplizumab at 51 μg/m², 103 μg/m², 207 μg/m², and 413 μg/m², on days 0-3, respectively, and one dose of 826 μg/m² on each of days 4-13. In certain embodiments, the prophylactically effective amount delays median time to clinical diagnosis of T1D by at least 50%, at least 80%, or at least 90%, or at least 12 months, at least 18 months, at least 24 months, at least 36 months, at least 48 months, or at least 60 months, or longer.

In certain embodiments, the course of dosing with the anti-CD3 antibody such as teplizumab can be repeated at 2 month, 4 month, 6 month, 8 month, 9 month, 10 month, 12 month, 15 month, 18 month, 24 month, 30 month, or 36 month intervals. In specific embodiments efficacy of the treatment with the anti-CD3 antibody such as teplizumab is determined as described herein or as is known in the art at 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, or 36 months subsequent to the previous treatment.

In another embodiment, a subject is administered one or more unit doses of approximately 0.5-50 ug/kg, approximately 0.5-40 ug/kg, approximately 0.5-30 ug/kg, approximately 0.5-20 ug/kg, approximately 0.5-15 ug/kg, approximately 0.5-10 ug/kg, approximately 0.5-5 ug/kg, approximately 1-5 ug/kg, approximately 1-10 ug/kg, approximately 20-40 ug/kg, approximately 20-30 ug/kg, approximately 22-28 ug/kg or approximately 25-26 ug/kg of the anti-CD3 antibody such as teplizumab to prevent, treat or ameliorate one or more symptoms of T1D. In another embodiment, a subject is administered one or more unit doses of about 200 ug/kg, 178 ug/kg, 180 ug/kg, 128 ug/kg, 100 ug/kg, 95 ug/kg, 90 ug/kg, 85 ug/kg, 80 ug/kg, 75 ug/kg, 70 ug/kg, 65 ug/kg, 60 ug/kg, 55 ug/kg, 50 ug/kg, 45 ug/kg, 40 ug/kg, 35 ug/kg, 30 ug/kg, 26 ug/kg, 25 ug/kg, 20 ug/kg, 15 ug/kg, 13 ug/kg, 10 ug/kg, 6.5 ug/kg, 5 ug/kg, 3.2 ug/kg, 3 ug/kg, 2.5 ug/kg, 2 ug/kg, 1.6 ug/kg, 1.5 ug/kg, 1 ug/kg, 0.5 ug/kg, 0.25 ug/kg, 0.1 ug/kg, or 0.05 ug/kg of the anti-CD3 antibody such as teplizumab to prevent, treat or ameliorate one or more symptoms of T1D.

In particular embodiments, a subject is administered one or more doses of the anti-CD3 antibody such as teplizumab at about 5-1200 ug/m2, preferably, 51-826 ug/m2. In another embodiment, a subject is administered one or more unit doses of 1200 ug/m2, 1150 ug/m2, 1100 ug/m2, 1050 ug/m2, 1000 ug/m2, 950 ug/m2, 900 ug/m2, 850 ug/m2, 800 ug/m2, 750 ug/m2, 700 ug/m2, 650 ug/m2, 600 ug/m2, 550 ug/m2, 500 ug/m2, 450 ug/m2, 400 ug/m2, 350 ug/m2, 300 ug/m2, 250 ug/m2, 200 ug/m2, 150 ug/m2, 100 ug/m2, 50 ug/m2, 40 ug/m2, 30 ug/m2, 20 ug/m2, 15 ug/m2, 10 ug/m2, or 5 ug/m2 of the anti-CD3 antibody such as teplizumab to prevent, treat, slow the progression of, delay the onset of or ameliorate one or more symptoms of T1D.

In another embodiment, the subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of the anti-CD3 antibody such as teplizumab, wherein the course of treatment is administered over 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days or 14 days. In one embodiment, the treatment regimen comprises administering doses of the prophylactically effective amount every day, every 2nd day, every 3rd day or every 4th day. In certain embodiments, the treatment regimen comprises administering doses of the prophylactically effective amount on Monday, Tuesday, Wednesday, Thursday of a given week and not administering doses of the prophylactically effective amount on Friday, Saturday, and Sunday of the same week until 14 doses, 13, doses, 13 doses, 12 doses, 11 doses, 10 doses, 9 doses, or 8 doses have been administered. In certain embodiments the dose administered is the same each day of the regimen.

In certain embodiments, a subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of the anti-CD3 antibody such as teplizumab, wherein the prophylactically effective amount is 200 ug/kg/day, 175 ug/kg/day, 150 ug/kg/day, 125 ug/kg/day, 100 ug/kg/day, 95 ug/kg/day, 90 ug/kg/day, 85 ug/kg/day, 80 ug/kg/day, 75 ug/kg/day, 70 ug/kg/day, 65 ug/kg/day, 60 ug/kg/day, 55 ug/kg/day, 50 ug/kg/day, 45 ug/kg/day, 40 ug/kg/day, 35 ug/kg/day, 30 ug/kg/day, 26 ug/kg/day, 25 ug/kg/day, 20 ug/kg/day, 15 ug/kg/day, 13 ug/kg/day, 10 ug/kg/day, 6.5 ug/kg/day, 5 ug/kg/day, 3.2 ug/kg/day, 3 ug/kg/day, 2.5 ug/kg/day, 2 ug/kg/day, 1.6 ug/kg/day, 1.5 ug/kg/day, 1 ug/kg/day, 0.5 ug/kg/day, 0.25 ug/kg/day, 0.1 ug/kg/day, or 0.05 ug/kg/day; and/or wherein the prophylactically effective amount is 1200 ug/m2/day, 1150 ug/m2/day, 1100 ug/m2/day, 1050 ug/m2/day, 1000 ug/m2/day, 950 ug/m2/day, 900 ug/m2/day, 850 ug/m2/day, 800 ug/m2/day, 750 ug/m2/day, 700 ug/m2/day, 650 ug/m2/day, 600 ug/m2/day, 550 ug/m2/day, 500 ug/m2/day, 450 ug/m2/day, 400 ug/m2/day, 350 ug/m2/day, 300 ug/m2/day, 250 ug/m2 day, 200 ug/m2/day, 150 ug/m2/day, 100 ug/m2/day, 50 ug/m2/day, 40 ug/m2 day, 30 ug/m2/day, 20 ug/m2/day, 15 ug/m2/day, 10 ug/m2/day, or 5 ug/m2/day.

In another embodiment, the intravenous dose of 1200 ug/m2 or less, 1150 ug/m2 or less, 1100 ug/m2 or less, 1050 ug/m2 or less, 1000 ug/m2 or less, 950 ug/m2 or less, 900 ug/m2 or less, 850 ug/m2 or less, 800 ug/m2 or less, 750 ug/m2 or less, 700 ug/m2 or less, 650 ug/m2 or less, 600 ug/m2 or less, 550 ug/m2 or less, 500 ug/m2 or less, 450 ug/m2 or less, 400 ug/m2 or less, 350 ug/m2 or less, 300 ug/m2 or less, 250 ug/m2 or less, 200 ug/m2 or less, 150 ug/m2 or less, 100 ug/m2 or less, 50 ug/m2 or less, 40 ug/m2 or less, 30 ug/m2 or less, 20 ug/m2 or less, 15 ug/m2 or less, 10 ug/m2 or less, or 5 ug/m2 or less of the anti-CD3 antibody such as teplizumab is administered over about 24 hours, about 22 hours, about 20 hours, about 18 hours, about 16 hours, about 14 hours, about 12 hours, about 10 hours, about 8 hours, about 6 hours, about 4 hours, about 2 hours, about 1.5 hours, about 1 hour, about 50 minutes, about 40 minutes, about 30 minutes, about 20 minutes, about 10 minutes, about 5 minutes, about 2 minutes, about 1 minute, about 30 seconds or about 10 seconds to prevent, treat or ameliorate one or more symptoms of type 1 diabetes. The total dosage over the duration of the regimen is preferably a total of less than 9000 ug/m2, 8000 ug/m2, 7000 ug/m2, 6000 ug/m2, and may be less than 5000 ug/m2, 4000 ug/m2, 3000 ug/m2, 2000 ug/m2, or 1000 ug/m2. In specific embodiments, the total dosage administered in the regimen is 100 ug/m2 to 200 ug/m2, 100 ug/m2 to 500 ug/m2, 100 ug/m2 to 1000 ug/m2, or 500 ug/m2 to 1000 ug/m2.

In preferred embodiments, the dose escalates over the first fourth, first half or first ⅔ of the doses (e.g., over the first 2, 3, 4, 5, or 6 days of a 10, 12, 14, 16, 18 or 20 day regimen of one dose per day) of the treatment regimen until the daily prophylactically effective amount of the anti-CD3 antibody such as teplizumab is achieved. In certain embodiments, a subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of the anti-CD3 antibody such as teplizumab, wherein the prophylactically effective amount is increased by, e.g., 0.01 ug/kg, 0.02 ug/kg, 0.04 ug/kg, 0.05 ug/kg, 0.06 ug/kg, 0.08 ug/kg, 0.1 ug/kg, 0.2 ug/kg, 0.25 ug/kg, 0.5 ug/kg, 0.75 ug/kg, 1 ug/kg, 1.5 ug/kg, 2 ug/kg, 4 ug/kg, 5 ug/kg, 10 ug/kg, 15 ug/kg, 20 .XI.g/kg, 25 ug/kg, 30 ug/kg, 35 ug/kg, 40 ug/kg, 45 ug/kg, 50 ug/kg, 55 ug/kg, 60 ug/kg, 65 ug/kg, 70 ug/kg, 75 ug/kg, 80 ug/kg, 85 ug/kg, 90 ug/kg, 95 ug/kg, 100 ug/kg, or 125 ug/kg each day; or increased by, e.g., 1 ug/m2, 5 ug/m2, 10 ug/m2, 15 ug/m2, 20 ug/m2, 30 ug/m2, 40 ug/m2, 50 ug/m2, 60 ug/m2, 70 ug/m2, 80 ug/m2, 90 ug/m2, 100 ug/m2, 150 ug/m2, 200 ug/m2, 250 ug/m2, 300 ug/m2, 350 ug/m2, 400 ug/m2, 450 ug/m2, 500 ug/m2, 550 ug/m2, 600 ug/m2, or 650 ug/m2, each day as treatment progresses. In certain embodiments, a subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of the anti-CD3 antibody such as teplizumab, wherein the prophylactically effective amount is increased by a factor of 1.25, a factor of 1.5, a factor of 2, a factor of 2.25, a factor of 2.5, or a factor of 5 until the daily prophylactically effective amount of the anti-CD3 antibody such as teplizumab is achieved.

In a specific embodiment, a subject is intramuscularly administered one or more doses of a 200 ug/kg or less, preferably 175 ug/kg or less, 150 ug/kg or less, 125 ug/kg or less, 100 ug/kg or less, 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or 0.5 ug/kg or less of the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab, to prevent, treat or ameliorate one or more symptoms of T1D.

In another embodiment, a subject is subcutaneously administered one or more doses of a 200 ug/kg or less, preferably 175 ug/kg or less, 150 ug/kg or less, 125 ug/kg or less, 100 ug/kg or less, 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or 0.5 ug/kg or less of the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab, to prevent, treat or ameliorate one or more symptoms of T1D.

In another embodiment, a subject is intravenously administered one or more doses of a 100 ug/kg or less, preferably 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or 0.5 ug/kg or less of the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab, to prevent, treat or ameliorate one or more symptoms of T1D. In another embodiment, the intravenous dose of 100 ug/kg or less, 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or 0.5 ug/kg or less of the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab, is administered over about 6 hours, about 4 hours, about 2 hours, about 1.5 hours, about 1 hour, about 50 minutes, about 40 minutes, about 30 minutes, about 20 minutes, about 10 minutes, about 5 minutes, about 2 minutes, about 1 minute, about 30 seconds or about 10 seconds to prevent, treat or ameliorate one or more symptoms of T1D.

In another embodiment, a subject is orally administered one or more doses of a 100 ug/kg or less, preferably 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or 0.5 ug/kg or less of the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab, to prevent, treat or ameliorate one or more symptoms of T1D. In another embodiment, the oral dose of 100 ug/kg or less, 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or 0.5 ug/kg or less of the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab, is administered over about 6 hours, about 4 hours, about 2 hours, about 1.5 hours, about 1 hour, about 50 minutes, about 40 minutes, about 30 minutes, about 20 minutes, about 10 minutes, about 5 minutes, about 2 minutes, about 1 minute, about 30 seconds or about 10 seconds to prevent, treat or ameliorate one or more symptoms of T1D.

In specific embodiments in which escalating doses are administered for the first days of the dosing regimen, the dose on day 1 of the regimen is 5-100 ug/m2/day, preferably 51 ug/m2/day and escalates to the daily dose as recited immediately above by day 3, 4, 5, 6 or 7. For example, on day 1, the subject is administered a dose of approximately 51 ug/m²/day, on day 2 approximately 103 ug/m²/day, on day 3 approximately 207 ug/m²/day, on day 4 approximately 413 ug/m²/day and on subsequent days of the regimen (e.g., days 5-14) 826 ug/m²/day. In another embodiment, on day 1, the subject is administered a dose of approximately 227 ug/m²/day, on day 2 approximately 459 ug/m²/day, on day 3 and subsequent days, approximately 919 ug/m²/day. In another embodiment, on day 1, the subject is administered a dose of approximately 284 ug/m²/day, on day 2 approximately 574 ug/m²/day, on day 3 and subsequent days, approximately 1148 ug/m²/day.

In other embodiments, the initial dose is ¼, to ½, to equal to the daily dose at the end of the regimen but is administered in portions at intervals of 6, 8, 10 on 12 hours. For example, a 13 ug/kg/day dose is administered in four doses of 3-4 ug/kg at intervals of 6 hours to reduce the level of cytokine release caused by administration of the antibody. In specific embodiments, to reduce the possibility of cytokine release and other adverse effects, the first 1, 2, 3, or 4 doses or all the doses in the regimen are administered more slowly by intravenous administration. For example, a dose of 51 ug/m²/day may be administered over about 5 minutes, about 15 minutes, about 30 minutes, about 45 minutes, about 1 hour, about 2 hours, about 4 hours, about 6 hours, about 8 hours, about 10 hours, about 12 hours, about 14 hours, about 16 hours, about 18 hours, about 20 hours, and about 22 hours. In certain embodiments, the dose is administered by slow infusion over a period of, e.g., 20 to 24 hours. In specific embodiments, the dose is infused in a pump, preferably increasing the concentration of antibody administered as the infusion progresses.

In other embodiments, a set fraction of the doses for the 51 ug/m²/day to 826 ug/m²/day regimen described above is administered in escalating doses. In certain embodiments, the fraction is 1/10, ¼, ⅓, ½, ⅔ or ¾ of the daily doses of the regimens described above. Accordingly, when the fraction is 1/10, the daily doses will be 5.1 ug/m² on day 1, 10.3 ug/m² on day 2, 20.7 g/m² on day 3, 41.3 ug/m² on day 4 and 82.6 ug/m² on days 5 to 14. When the fraction is ¼, the doses will be 12.75 ug/m² on day 1, 25.5 ug/m² on day 2, 51 ug/m² on day 3, 103 ug/m² on day 4, and 207 ug/m² on days 5 to 14. When the fraction is ⅓, the doses will be 17 ug/m² on day 1, 34.3 ug/m² on day 2, 69 ug/m² on day 3, 137.6 ug/m² on day 4, and 275.3 ug/m² on days 5 to 14. When the fraction is ½, the doses will be 25.5 ug/m² on day 1, 51 ug/m² on day 2, 103 ug/m² on day 3, 207 ug/m² on day 4, and 413 ug/m² on days 5 to 14. When the fraction is ⅔, the doses will be 34 ug/m² on day 1, 69 ug/m² on day 2, 137.6 ug/m² on day 3, 275.3 ug/m² on day 4, and 550.1 ug/m² on days 5 to 14. When the fraction is ¾, the doses will be 38.3 ug/m² on day 1, 77.3 ug/m² on day 2, 155.3 ug/m² on day 3, 309.8 ug/m² on day 4, and 620 ug/m² on days 5 to 14. In other embodiments, the regimen is identical to one of those described above but only over days 1 to 4, days 1 to 5, or days 1 to 6. For example, in a particular embodiment, the doses will be 17 ug/m² on day 1, 34.3 ug/m² on day 2, 69 ug/m² on day 3, 137.6 ug/m² on day 4, and 275.3 ug/m² on days 5 and 6.

In specific embodiments, the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab, is not administered by daily doses over a number of days, but is rather administered by infusion in an uninterrupted manner over 4 hours, 6 hours, 8 hours, 10 hours, 12 hours, 15 hours, 18 hours, 20 hours, 24 hours, 30 hours or 36 hours. The infusion may be constant or may start out at a lower dosage for, for example, the first 1, 2, 3, 5, 6, or 8 hours of the infusion and then increase to a higher dosage thereafter. Over the course of the infusion, the patient receives a dose equal to the amount administered in the 5 to 20 day regimens set forth above. For example, a dose of approximately 150 ug/m², 200 ug/m², 250 ug/m², 500 ug/m², 750 ug/m², 1000 ug/m², 1500 ug/m², 2000 ug/m², 3000 ug/m², 4000 ug/m², 5000 ug/m², 6000 ug/m², 7000 ug/m², 8000 ug/m², or 9000 ug/m². In particular, the speed and duration of the infusion is designed to minimize the level of free anti-CD3 antibody such as teplizumab, otelixizumab or foralumab in the subject after administration. In certain embodiments, the level of free anti-CD3 antibody such as teplizumab should not exceed 200 ng/ml free antibody. In addition, the infusion is designed to achieve a combined T cell receptor coating and modulation of at least 50%, 60%, 70%, 80%, 90%, 95% or of 100%.

In other embodiments, the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab is administered chronically to treat, prevent, or slow or delay the onset or progression, or ameliorate one or more symptoms of type 1 diabetes. For example, in certain embodiments, a low dose of the anti-CD3 antibody such as teplizumab is administered once a month, twice a month, three times per month, once a week or even more frequently either as an alternative to the 6 to 14 day dosage regimen discussed above or after administration of such a regimen to enhance or maintain its effect. Such a low dose may be anywhere from 1 ug/m² to 100 ug/m², such as approximately 5 ug/m², 10 ug/m², 15 ug/m², 20 ug/m², 25 ug/m², 30 ug/m², 35 ug/m², 40 ug/m², 45 ug/m², or 50 ug/m².

In other embodiments, the subject may be re-dosed at some time subsequent to administration of the the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab dosing regimen, for example, based upon one or more physiological parameters or may be done as a matter of course. Such redosing may be administered and/or the need for such redosing evaluated 2 months, 4 months, 6 months, 8 months, 9 months, 1 year, 15 months, 18 months, 2 years, 30 months or 3 years after administration of a dosing regimen and may include administering a course of treatment every 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 30 months or 3 years indefinitely.

EXAMPLE

Abstract

Background: Type 1 diabetes (T1D) is a chronic autoimmune disease that leads to destruction of insulin producing beta cells and dependence on exogenous insulin for survival. Some interventions have shown success in attenuating the loss of insulin production in patients who present with clinical disease but no intervention to date has been able to affect progression to the disease in individuals who are at high risk for its development.

Methods: We conducted a randomized placebo controlled double blind study of teplizumab (FcR non-binding anti-CD3 mAb) in non-diabetic relatives of patients with T1D who were at high risk for the clinical disease. The patients were randomized to a single 14 day course of the drug or placebo and followed for the disease progression using oral glucose tolerance tests at approximately 6 month intervals.

Results: A total of 76 subjects were randomized, 44 in the teplizumab and 32 in the placebo arms. Seventy-two percent of the participants were children. Teplizumab treatment delayed the median time to clinical diagnosis of T1D from 24.4 to 48.4 months (Cox proportional hazards, p=0.006) and the rate of diabetes development from 9.8% to 4.1% per year. Drug treatment increased the proportion of TIGIT+KLRG1+CD8+ T-cells. Participants who did not have antibodies against ZnT8 (p=0.01), who were HLA-DR4+(p=0.006), and not HLA-DR3+(p=0.05) were most likely to respond to teplizumab.

Conclusions: Teplizumab can delay the diagnosis of T1D in high-risk individuals. Subgroups of individuals may be more likely to respond to therapy and the effects.

Methods

Trial Participants

Participants were identified through the TrialNet Natural History Study¹⁴. The trial was conducted between July 2011 and November 2018 at sites in the United States, Canada and Germany. Institutional Review Board (IRB) approval was obtained at each participating site. The patients, their parents, or both provided written informed consent prior to trial entry.

Eligible participants were nondiabetic relatives of patients with type 1 diabetes, age ≥8 years at time of randomization, who were at high risk for development of clinical diabetes. They had 2 or more diabetes-related autoantibodies on 2 sample collections within 6 months prior to randomization. In addition, they had abnormal glucose tolerance on oral glucose tolerance test (OGTT), defined to be a fasting glucose level of 110-125 mg/dL, or 2 hour plasma of >140 and <200 mg/dL, or an intervening glucose value at 30, 60, or 90 minutes on OGTT >200 mg/d on two occasions within 52 days of enrollment. The protocol was amended in 2014 to allow enrollment of participants <age 18 with a single abnormal OGTT because the rates of T1D progression were similar with and without a confirmatory OGTT in this age group. In these 8 subjects (5 in teplizumab and 3 in placebo arms) the second pre-treatment OGTT was done on the first day of study drug administration. Individuals with other significant medical history, abnormal laboratory chemistries or blood counts were excluded.

Patient Identification

Subjects were identified in the TrialNet Pathway to Prevention (PTP) study. See FIG. 5. The PTP study enrolled first degree relatives of patients with T1D, ages 1-45, and up to age 20 in second- or third-degree relatives, evaluated diabetes autoantibodies to microinsulin (mIAA), glutamic acid decarboxylase-65 (GAD), and insulinoma-associated antigen-2 (IA-2, or ICA512). Islet cell (ICA) and zinc transporter 8 (ZnT8) autoantibodies were measured if at least 1 other antibody tested positive.

Trial Design and Intervention

Participants were randomized to receive either teplizumab or placebo, in equal allocations to each group. Randomization was stratified at each TrialNet study site by age (< or >18 years), and glucose during the pre-randomization OGTT status. Treatment assignment was double masked.

Participants received a 14-day course of teplizumab or placebo administered as an outpatient in a clinical research center using the drug dosing regimen described previously^(9,10). Specifically, those assigned to active study drug received teplizumab by daily IV infusions of teplizumab according to the following daily schedule: 51 micrograms/meter squared (μg/m²), 103 μg/m², 207 μg/m², and 413 μg/m² on Study Days 0-3, respectively, and one dose of 826 μg/m² on each of Study Days 4-13. Participants randomized to the placebo arm received a 14-day course of matching IV saline. Participants received ibuprofen and diphenhydramine prior to infusions on the first 5 days, and further dosing with ibuprofen, diphenhydramine and/or acetaminophen thereafter as needed for symptomatic relief. Protocol defined stopping criteria for study drug infusions were followed.

During the entire study, all subjects had interim contact with study personnel for formal inquiry about adverse events and symptoms of diabetes.

End Points and Assessments

The primary outcome was the elapsed time from randomization to the diagnosis of diabetes, using criteria defined by the American Diabetes Association¹⁵.

Scheduled OGTT tests were done at 3 and 6 months after the infusion, and every 6 months thereafter. Screening random glucoses, were performed at 3 month intervals and OGTT tests were performed if the random glucose was >200 mg/dl with symptoms of diabetes. Diabetic OGTT tests needed to be sequentially confirmed and the date of diagnosis was identified as the time of the 2^(nd) diagnostic test. Outcome reviews were conducted without knowledge of treatment assignment.

Blood samples were analyzed centrally at TrialNet core laboratories with methods described in the Laboratory Methods. Flow cytometry was used to analyse CD8+ T-cell subsets in the peripheral blood (FIG. 4).

Laboratory Methods

C-peptide was measured from frozen plasma by two-site immunoenzymometric assay (Tosoh Bioscience, South San Francisco, Calif.). HbA_(1c) was measured using ion-exchange high performance liquid chromatography (Variant II, Bio-Rad Diagnostics, Hercules, Calif.). Reliability coefficients for each assay were above 0.99 from split duplicate samples. mIAA, GAD-65Ab, ICA-512Ab, ZnT8A were measured using radio-immunobinding assays at the Barbara Davis Diabetes Center, Anschultz C O, and ICA using indirect immunofluorescence at the University of Florida at Gainesville. C-peptide, glucose and HbA1c were measured at the Northwest Research Laboratory, Seattle, Wash. C-peptide was measured from frozen plasma by two-site immunoenzymometric assay (Tosoh Bioscience, South San Francisco, Calif.) at the HbA_(1c) was measured using ion-exchange high performance liquid chromatography (Variant II, Bio-Rad Diagnostics, Hercules, Calif.). Reliability coefficients for each assay were above 0.99 from split duplicate samples. EBV and CMV viral loads were measured in whole blood at the University of Colorado using previously described methods¹.

Flow Cytometry

Peripheral blood mononuclear cells (PBMC) were processed and stored at the NIDDK repository. Frozen vials of PBMC were sent to Benaroya Research Institute for analysis by flow cytometry with antibody panels shown in FIG. 4. T-cell phenotyping was performed on PBMC as previously described on an LSR-Fortessa (BD Biosciences) with FACS Diva software and analyzed with FlowJo software version 9.5 (Tree Star, Ashland, Oreg.). The frequency of CD8+ T-cells that were TIGIT+KLRG+CD57−, TIGIT−KLRG1−CD57−, or CD4+CD127^(lo) Foxp3+(CD4+Tregs) were determined as described previously². The quadrants were placed based on staining controls.

Trial Oversight

The study was developed and conducted by Type 1 Diabetes TrialNet, funded by the National Institutes of Health and the Juvenile Diabetes Research Foundation.

The study coordination, laboratory tests, and data management were conducted centrally, with the exception of CBC and differentials and routine chemistries that were analysed at the infusion sites. An independent medical monitor (masked to treatment assignment) reviewed all accruing safety data.

Statistical Analysis

The cumulative incidence of diabetes onset over time since randomization within each group was estimated from a Kaplan-Meier estimate of the “diabetes-free” survival function¹⁶. The difference between treatment groups in the 6-month interval cumulative incidence functions was estimated by the hazard ratio (HR) and hypothesis tests employed the likelihood ratio test; both based on the Cox Proportional Hazards (PH) model¹⁷. The critical value for the test statistic for the primary hypothesis was determined by a group-sequential procedure.

Because of slower than expected accrual rates, the original protocol (n=144 subjects was revised to detect a 60% (previously 50%) decrease in the hazard rate (HR=0.4) with 80% statistical power at an alpha level of 0.025 (one-sided). This set the study goal to enroll at least 71 subjects and follow them until 40 subjects were diagnosed with TID¹⁸.

Data on safety and efficacy were evaluated twice yearly by an independent Data Safety Monitoring Board (DSMB). An interim analysis was conducted when 50% of the expected number of T1D cases was observed at which time a formal comparison was presented to the DSMB and Lan DeMets stopping rules were employed¹⁹. Data were analyzed according to the intention-to-treat principle. Tests of significance reported herein were one-sided using a threshold of significance of 0.025 in accordance with the design but were two-sided for treatment interaction tests. Unless indicated, 95% confidence intervals are reported. Flow cytometry data were analyzed by a repeated measures ANOVA. Statistical analyses were performed using either TIBCO Spotfire S+8.2 Workbench or SAS 9.4.

Results

Patients: Of the 112 subjects screened for eligibility, 76 were enrolled: 44 were randomized to teplizumab and 32 to placebo (FIG. 1). The randomization process resulted in unequal proportions in the study groups, probably explained by study sites with a small number of enrolled subjects (<3) in whom randomization may have resulted in unequal distribution between the arms. All participants had at least 2+ autoantibodies and 71% of the participants had 3 or more. The treatment arms were generally well balanced (Table 1). The majority of subjects (55, 72%) were children and about half were siblings of patients with T1D. Of the subjects <age 18, 47 confirmed a dysglycemic OGTT prior to randomization. Of those randomized after a single dysglycemic OGTT, 2 had “diabetic” and 6 had normal pre-treatment OGTTs: these 8 individuals were enrolled on the basis of the dysglycemia OGTT prior to enrollment.

Ninety-three percent (41/44) and 87.5% (28/32) of subjects randomized to the teplizumab and placebo groups, respectively, completed the 14 days of drug therapy. The total dose of teplizumab administered was 9.¹⁴ (IQR:9.01-9.37) μg/m². Three drug-treated and 4 placebo-treated subjects did not complete treatment because of laboratory abnormalities (n=4), inability to establish intravenous access (n=2), or rash (n=1). Median follow-up was 745 days (range 74-2683 days). The duration of follow up was more than 3 years in 75% of subjects. T1D was diagnosed in 42 (55%) of the participants.

Efficacy: Treatment with a single course of teplizumab delayed the time to T1D (FIG. 2A, p=0.006): The median times to T1D was 24.4 mos in the placebo and 48.4 mos in the teplizumab groups (hazard ratio=0.437 (IQR: 0.229, 0.832). The annualized rate of T1D development was 9.8% and 4.1% for the placebo and teplizumab groups, respectively. Twenty-five (57%) subjects from the teplizumab and 9 (28%) of the placebo group were T1D-free at the conclusion of the trial (Chi-squared, p=0.012). The hazard ratio remained statistically different when adjusted for prespecified covariates of age, glucose during the OGTT prior to randomization, or anti-GAD65 antibody.

The overall rate of progression to T1D was greatest in the first year after entry into the trial (n=17, 41%) compared to year 2 (n=10, 24%), 3, (n=6, 14%), or 4 (n=5, 12%). The effect of the teplizumab treatment was also greatest during that time (FIG. 1B). The hazard ratios were lowest in the first 36 months after study enrollment and remained relatively constant and statistically significant (p<0.01) after that time.

Treatment administration and safety: In general, teplizumab treatment was well tolerated—adverse events designated as possibly, probably, or definitely related to study drug are shown in Table 2. The lymphocyte count declined to a nadir on day 5 by 72.3% (IQR 82.1, 68.4%)(p<0.0001) but recovered quickly afterwards. Fifteen (34.1%) of the grade 3 events in the teplizumab group involved lymphopenia during the first 30 days after study drug administration. There were no cases of lymphopenia after day 30 in either treatment arms (FIG. 1C). A spontaneously resolving rash, as previously noted, occurred in 36% of drug treated subjects¹¹. The rates of infection were similar in the two treatment arms.

At entry, 30 subjects (39%) (16 teplizumab and 14 placebo treated) had antibodies against EBV virus. After study drug treatment, week 3-6, there were quantifiable EBV viral loads in 7 participants—all were in the teplizumab group. Of those with detectable viral loads, 1 had symptoms of pharyngitis, rhinorrhea, and cough on day 38. The EBV viral loads decreased to below the level of quantification between day 43 and 134 (average 74 days). At entry, 17 participants (10 teplizumab and 7 placebo) had antibodies against the CMV virus. One teplizumab subject, who was CMV seropositive, had detectable levels of CMV virus at day 20 that was undetectable by day 42.

Response biomarkers: We previously described changes in CD8+ T-cells such as expression of markers associated with reduced responsiveness TIGIT, KLRG1, and others, after teplizumab treatment^(12,13). To determine whether the clinical outcomes were associated with these changes in CD8+ T-cells, we compared the frequency of CD8+KLRG1+TIGIT+CD57− T-cells in the two treatment arms. Teplizumab treatment increased the frequency of these T-cells at month 3 and 6 compared to the baseline (p=0.009, 0.007 respectively) and the levels were higher in the teplizumab vs placebo treated participants at 3 mos and 6 mos (p=0.02, 0.04 respectively). (FIG. 3A, FIG. 6). We did not identify a change in these cells in the placebo treated subjects. Not all T-cell subsets were affected with teplizumab: There was not a significant change in CD4+ Tregs or CD8+KLRG1-TIGIT-CD57− cells in either group^(8,20) (FIGS. 7A, 7B).

To determine whether demographic characteristics of participants were associated with clinical responses, in a prespecified analysis, we analyzed the effects of teplizumab in subgroups of participants on the basis of age, HLA type, pre-treatment C-peptide and glucose during the OGTT, and autoantibodies (FIG. 3B). Participants who did not have anti-ZnT8 antibodies showed a greater response to teplizumab compared to those who did (p=0.004)(FIG. 3C). The presence or absence of other autoantibodies was not associated with the clinical responses. 49% and 65% of the teplizumab subjects were HLA-DR3 and HLA-DR4 respectively. The presence of HLA-DR4 and absence of HLA-DR3 were associated with more robust responses to teplizumab (p=0.004 and 0.01, respectively, two-sided tests) (FIG. 3D, E).

Discussion

In this Phase II study, we found that a single course of teplizumab significantly slowed progression to T1D in non-diabetic relatives who had abnormal glucose tolerance during an OGTT at study entry. The median delay in the diagnosis of diabetes was 2 years, and at the conclusion of the trial, the frequency of diabetes-free individuals was double in the drug (57%) vs placebo-treated subjects (28%). The safety experience in children and adults was good with expected adverse events of rash and transient lymphopenia. To our knowledge, this is the first therapy that has delayed or prevented the onset of T1D. The delay in onset of clinical T1D with the challenges of daily management is of clinical importance. Moreover, a younger age of diagnosis is associated with worse outcomes^(2,4). Prior large well designed but unsuccessful prevention trials have not utilized immunotherapy directed against immune cells, and our findings support the notion that T1D is a chronic T-cell mediated disease^(21,22). Furthermore, the observation that this therapy impacts disease progression before, and loss of beta cell function after diagnosis suggests that there is a continuum in the autoimmune process, and validates the effort to use immunomodulation prior to the onset of clinical disease^(9-11,23-25).

The effects of the drug were greatest in the first three years after administration. Forty-one percent of those who developed diabetes did so in the first year after randomization and the HR was lowest at that time for those exposed to teplizumab. The relatively rapid rate of progression to diabetes in the placebo group reflects the very high risk of these individuals⁵. Indeed, our decision to enroll these subjects, who did not have clinical disease, reflects the inevitability of progression when >2 autoantibodies and dysglycemia are found consistent with our report of high rates of beta cell killing in these individuals²⁶. In addition, the rapid development of clinical T1D may reflect the enrichment of pediatric participants (72.4%) in whom the rate of progression is rapid^(27,28).

There were differences in the responses to teplizumab based on characteristics of the subjects at the time of study enrollment. The absence of one T1D-associated MHC allele, HLA-DR3, but the presence of another, HLA-DR4, and absence of anti-ZnT8 antibodies identified individuals who were most likely to respond. The MHC may modulate responsiveness to teplizumab through its effect on the T-cell repertoire, perhaps altering T-cell activation status and susceptibility to the drug effects. It is also possible that anti-ZnT8 antibodies are a marker for individuals with a more fulminant immune response, or other features that make their T-cells susceptible to teplizumab. We cannot be certain whether the treatment will be effective in those at earlier stages of the disease. Further immunologic and metabolic studies may identify features that define individuals who are most likely to benefit from this treatment.

The transient effects of the drug treatment on lymphocyte counts most likely reflects egress from the peripheral blood rather than cell depletion^(29,30). Our flow cytometry studies suggest that changes in the phenotype of CD8+ T-cells are a marker of clinical responses. These effects, associated with a non-responsive or “exhausted” phenotype, however, do not render the CD8+ T-cells inactive since there was a brisk response to EBV and CMV in those in whom there was an increase in viral load^(31,32). The functional effects of teplizumab on T-cells may be affected by their avidity for antigen: T-cells with a high avidity, e.g. viral antigen reactive cells may be unaffected while those with low avidity e.g. autoreactive T-cells, may be rendered inactive. Further studies with antigen reactive T-cells will be needed to address this hypothesis.

There are a few limitations to this clinical study to be considered. The cohort was relatively small and the rate of progression to T1D was rapid in the placebo group. The study subjects were relatives of patients with T1D, and therefore, we do not know whether these findings will be generally applicable to non-relatives who are found to be at-risk for T1D. Recent reports suggest that in genetically high risk individuals, the rates of diabetes are similar in non-relatives and relatives³³. Moreover, while reflecting the known incidence of disease, the population was overwhelmingly non-hispanic Caucasians. Increasing the median delay in disease onset would be ideal. In this study, the drug was only given for one course and our analysis of the HR suggests that repeated dosing may be needed to capture more individuals with active disease and to prolong the therapeutic effect^(9,25). Identifying the target population for treatment and the number of drug courses need to be explored.

In summary, this is the first trial to show delay or prevention of T1D. Because age of onset and duration of diabetes are important determinants for metabolic management and complications, and the daily burden of management, any time without diabetes has clinical significance. Selection of those who are most likely to respond, repeated dosing, or combinations of teplizumab with other agents with complementary mechanisms of action may enable prevention of clinical disease for extended periods of time.

TABLE 1 Subject characteristics at baseline by treatment group Subject Characteristic and Teplizumab Placebo Descriptive Statistic* Displayed N = 44 N = 32 Age - years Median  14 (12-22) 13 (11-6) Range 8.5-49.5 8.6-45.0 Male sex No. of subjects 25 (56.8) 17 (53.1) Race - No. of subjects White  44 (100.0) 30 (93.8) African American 0 (0.0) 0 (0.0) Asian 0 (0.0) 2 (6.2) Ethnicity - No. of subjects Non-Hispanic 43 (97.7) 31 (96.9) Relationship to index case - No. of subjects Sibling(s) 24 (54.5) 16 (50.0) Identical twin 4 (9.1) 0 (0.0) Offspring  6 (13.6)  6 (18.8) Parent  6 (13.6) 3 (9.4) Sibling and another first degree 2 (4.5) 3 (9.4) Second degree 2 (4.5) 3 (9.4) Third degree or further removed 0 (0.0) 1 (3.1) Autoantibodies Positive - No. of subjects Anti-GAD65 (harmonized) 40 (90.9) 28 (87.5) Micro Insulin 20 (45.5) 11 (34.4) Anti-IA-2 (harmonized) 27 (61.4) 24 (75.0) ICA 29 (65.9) 28 (87.5) Zinc Transporter 32 (72.7) 24 (75.0) Autoantibodies titer - median Anti-GAD65 (harmonized)    240 (76.8-464)    221 (42.3-520) Micro Insulin     0.0070 (0.0020-0.028)     0.0040 (0.0020-0.0168) Anti-IA-2 (harmonized)  52 (0-310)  187 (26-253) ICA  20 (0-200)  80 (20-160) Zinc Transporter     0.157 (0.0133-0.496)     0.096 (0.028-0.386) No. of Autoantibodies Positive{circumflex over ( )} 1 4 (9.1) 0 (0.0) 2 11 (25.0)  7 (21.9) 3 14 (31.8) 10 (31.3) 4 15 (34.1) 15 (46.9) Glycated hemoglobin - percent Median  5.2 (4.9-5.4)   5.3 (5.1 -5.4) Body Mass Index (kg/m2) Median    19.6 (17.3-25.4)    21.5 (18.2-24.7) Z-score BMI    0.259 (−0.754-1.19)    0.681 (0.339-1.11) C-peptide AUC Mean, OGTT † (nmol/L) Median    1.76 (1.47-2.18)    1.73 (1.44-2.36) HLA alleles present † - no. of subjects (%) Neither DR3 or DR4  5 (11.6) 3 (9.4) DR3 only 10 (23.3)  8 (25.0) DR4 only 17 (39.5) 14 (43.8) Both 11 (25.6)  7 (21.9) Subject Characteristic and Anti-CD3 MAB Placebo Descriptive Statistic* Displayed N = 44 N = 32 Age - years Median  14 (12-22)  13 (11-16) Range 8.5-49.5 8.6-45.0 Male sex No. of subjects 25 (56.8) 17 (53.1) Race - No. of subjects White  44 (100.0) 30 (93.8) African American 0 (0.0) 0 (0.0) Asian 0 (0.0) 2 (6.2) Ethnicity - No. of subjects Non-Hispanic 43 (97.7) 31 (96.9) Relationship to index case - No. of subjects Sibling(s) 24 (54.5) 16 (50.0) Identical twin 4 (9.1) 0 (0.0) Offspring  6 (13.6)  6 (18.8) Parent  6 (13.6) 3 (9.4) Sibling and another first degree 2 (4.5) 3 (9.4) Second degree 2 (4.5) 3 (9.4) Third degree or further removed 0 (0.0) 1 (3.1) Autoantibodies Positive - No. of subjects Anti-GAD65 (harmonized) 40 (90.9) 28 (87.5) Micro Insulin 20 (45.5) 11 (34.4) Anti-IA-2 (harmonized) 27 (61.4) 24 (75.0) ICA 29 (65.9) 28 (87.5) Zinc Transporter 32 (72.7) 24 (75.0) Autoantibodies titer - median Anti-GAD65 (harmonized)    240 (76.8-464)    221 (42.3-520) Micro Insulin     0.0070 (0.0020-0.028)     0.0040 (0.0020-0.0168) Anti-IA-2 (harmonized)  52 (0-310)  187 (26-253) ICA  20 (0-200)  80 (20-160) Zinc Transporter     0.157 (0.0133-0.496)     0.096 (0.028-0.386) No. of Autoantibodies Positive{circumflex over ( )} 1 4 (9.1) 0 (0.0) 2 11 (25.0)  7 (21.9) 3 14 (31.8) 10 (31.3) 4 15 (34.1) 15 (46.9) Glycated hemoglobin - percent Median  5.2 (4.9-5.4)  5.3 (5.1-5.4) Body Mass Index (kg/m²) Median    19.6 (17.3-25.4)    21.5 (18.2-24.7) Z-score BMI    0.259 (−0.754-1.19)    0.681 (0.339-1.11) C-peptide AUC Mean, OGTT † (nmol/L) Median    1.76 (1.47-2.18)    1.73 (1.44-2.36) HLA alleles present † - no. of subjects (%) Neither DR3 or DR4  5 (11.6) 3 (9.4) DR3 only 10 (23.3)  8 (25.0) DR4 only 17 (39.5) 14 (43.8) Both 11 (25.6)  7 (21.9) *Parenthetical value(s): The interquartile range is displayed with the median, and percent of subjects is displayed with the number of subjects. {circumflex over ( )}at the time of randomization. All subjects had at least 2+ autoantibodies prior to randomization. † Missing: HLA allele status missing for 1 subject

TABLE 2 Adverse events designated as possibly, probably, or definitely related to study drug during active follow-up Teplizumab Placebo No. of No. of No. of No. of Adverse Effect Category Events Subjects Events Subjects Blood/Bone Marrow*** 45 33 (75)  2 2 (6.2) Dermatology/Skin*** 17 16 (36.4) 1 1 (3.1) Pain 11  5 (11.4) 5 3 (9.4) Infection 8  5 (11.4) 5 3 (9.4) Gastrointestinal 5 4 (9.1) 3 3 (9.4) Metabolic/Laboratory 7 4 (9.1) 2 2 (6.2) Pulmonary/Upper Respiratory 6 4 (9.1) 0 0 (0)  Constitutional Symptoms 3 2 (4.5) 0 0 (0)  Allergy/Immunology 2 2 (4.5) 0 0 (0)  Cardiac General 1 1 (2.3) 1 1 (3.1) Endocrine 0 0 (0)  2 2 (6.2) Vascular 1 1 (2.3) 1 1 (3.1) Neurology 1 1 (2.3) 0 0 (0)  Ocular/Visual 1 1 (2.3) 0 0 (0)  Musculoskeletal/Soft Tissue 2 1 (2.3) 0 0 (0)  Hepatobiliary/Pancreas 0 0 (0)  1 1 (3.1) Syndromes 1 1 (2.3) 0 0 (0)  Hemorrhage/Bleeding 1 1 (2.3) 0 0 (0)  Total Events and Subjects 112 44 (100)  23 32 (100)  ***p < 0.001 Teplizumab vs placebo

Modifications and variations of the described methods and compositions of the present disclosure will be apparent to those skilled in the art without departing from the scope and spirit of the disclosure. Although the disclosure has been described in connection with specific embodiments, it should be understood that the disclosure as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the disclosure are intended and understood by those skilled in the relevant field in which this disclosure resides to be within the scope of the disclosure as represented by the following claims.

INCORPORATION BY REFERENCE

All patents and publications mentioned in this specification are herein incorporated by reference to the same extent as if each independent patent and publication was specifically and individually indicated to be incorporated by reference.

REFERENCES

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The invention claimed is:
 1. A method of preventing or delaying the onset of clinical type I diabetes (T1D), comprising: providing a non-diabetic subject who is (1) in an immunospecific assay, free of antibodies against zinc transporter 8 (ZnT8), (2) HLA-DR4+, and (3) not HLA-DR3+; and administering an agent comprising a prophylactically effective amount of teplizumab to the non-diabetic subject.
 2. The method of claim 1, further comprising determining that the non-diabetic subject is (1), in an immunospecific assay, free of antibodies against zinc transporter 8(ZnT8), (2) HLA-DR4+, and (3) not HLA-DR3+.
 3. The method of claim 1, wherein the non-diabetic subject is a relative of a patient with T1D.
 4. The method of claim 1, wherein the non-diabetic subject has two or more diabetes-related autoantibodies selected from islet cell antibodies (ICA), insulin autoantibodies (IAA), antibodies to glutamic acid decarboxylase (GAD), or antibodies to tyrosine phosphatase (IA-2/ICA512).
 5. The method of claim 1, wherein the non-diabetic subject has abnormal glucose tolerance on oral glucose tolerance test (OGTT).
 6. The method of claim 5, wherein the abnormal glucose tolerance on OGTT is a fasting glucose level of 110-125 mg/dL.
 7. The method of claim 5, wherein the abnormal glucose tolerance on OGTT is a 2 hour plasma of ≥140 and <200 mg/dL.
 8. The method of claim 5, wherein the abnormal glucose tolerance on OGTT is a glucose value at 30, 60, or 90 minutes on OGTT>200 mg/dL.
 9. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course of subcutaneous (SC) injection or intravenous (IV) infusion or oral administration of teplizumab at from about 10 to about 1000 micrograms/meter squared (μg/m²).
 10. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course of subcutaneous (SC) injection of teplizumab at about 10-1000 micrograms/meter squared (μg/m²).
 11. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course of intravenous (IV) infusion of teplizumab at about 10-1000 micrograms/meter squared (μg/m²).
 12. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course of oral administration of teplizumab at about 10-1000 micrograms/meter squared (μg/m²).
 13. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course of subcutaneous (SC) injection or intravenous (IV) infusion or oral administration of teplizumab at from about 5 to about 1200 μg/m².
 14. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course of subcutaneous (SC) injection of teplizumab at from about 5 to about 1200 μg/m².
 15. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course of intravenous (IV) infusion of teplizumab at from about 5 to about 1200 μg/m².
 16. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course of oral administration of teplizumab at from about 5 to about 1200 μg/m².
 17. The method of claim 1, wherein the prophylactically effective amount comprises a 10 to 14 day course IV infusion at about 51 μg/m² on day 0, about 103 μg/m² on day 1, about 207 μg/m² on day 2, and about 413 μg/m² on day 3, and one dose of about 826 μg/m² on each of days 4 to
 13. 18. The method of claim 1, wherein the prophylactically effective amount delays median time to clinical diagnosis of T1D by from at least 50% to at least 90%.
 19. The method of claim 1, wherein the prophylactically effective amount delays median time to clinical diagnosis of T1D by from at least 12 months to at least 60 months.
 20. The method of claim 1, further comprising determining, by flow cytometry, a frequency of TIGIT+KLRG1+CD8+ T-cells in peripheral blood mononuclear cells of the non-diabetic subject, wherein an increase in the frequency after administrating teplizumab indicates responsiveness to teplizumab. 